OB 2

A nurse is assigned the task of educating a pregnant client about birth. Which nursing interventions should the nurse perform as a part of prenatal education for the client to ensure a positive birth experience? Select all that apply. a. Provide the client clear information on procedures involved. b. Encourage the client to have a sense of mastery and self-control. c. Encourage the client to have a positive reaction to pregnancy. d. Instruct the client to spend some time alone each day. e. Instruct the client to begin changing the home environment.

a, b, c. To ensure a positive birth experience for the client, the nurse should provide the client clear information on procedures involved, encourage the client to have a sense of mastery and self-control, and encourage the client to have a positive reaction to pregnancy. Instructing the client to spend some time alone is not an appropriate intervention; instead, the nurse should instruct the client to obtain positive support and avoid being alone. The client does not need to change the home environment; this does not ensure a positive birth experience.

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply. a. increase in heart rate b. increase in blood pressure c. increase in respiratory rate d. slight decrease in body temperature e. increase in gastric emptying and pH

a, b, c. When caring for a client in labor, the nurse should monitor for an increase in the heart rate by 10 to 20 bpm, an increase in systolic blood pressure by as much as 35 mm Hg, and an increase in respiratory rate. During labor, the nurse should monitor for a slight elevation in body temperature as a result of an increase in muscle activity. The nurse should also monitor for decreased gastric emptying and gastric pH, which increases the risk of vomiting with aspiration.

When teaching a group of nursing students about the different types of pelvis, the nurse describes which features of a gynecoid pelvis? Select all that apply. a. round-shaped inlet b. straight sacrum c. dull ischial spines d. wide pubic arch e. convergent side walls

a, c, d. The features of a gynecoid pelvis are oval-shaped inlet, dull ischial spines, and wide pubic arch. The birth of a baby is easiest in a gynecoid pelvis. Straight sacrum and convergent side walls are seen in an android pelvis.

A nurse is teaching a woman in her third trimester about Braxton Hicks contractions. When describing these contractions, which information would the nurse likely include? Select all that apply. a. "They usually feel like a tightening across the top of your uterus." b. "They typically last for about 3 minutes each time you have them." c. "They often spread downward before they go away." d. "They usually happen in a regular pattern." e. "They go away when you walk around or change position."

a, c, e. Braxton Hicks contractions are typically felt as a tightening or pulling sensation of the top of the uterus. They occur primarily in the abdomen and groin and gradually spread downward before relaxing. In contrast, true labor contractions are more commonly felt in the lower back. These contractions aid in moving the cervix from a posterior position to an anterior position. They also help in ripening and softening the cervix. However, the contractions are irregular and can be decreased by walking, voiding, eating, increasing fluid intake, or changing position. Braxton Hicks contractions usually last about 30 seconds but can persist for as long as 2 minutes. As birth draws near and the uterus becomes more sensitive to oxytocin, the frequency and intensity of these contractions increase. However, if the contractions last longer than 30 seconds and occur more often than four to six times an hour, the woman should be advised to contact her health care provider to be evaluated, especially if she is less than 39 weeks' pregnant.

The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording? a. Acceleration of at least 15 bpm for 15 seconds b. Increase in variability by 27 bpm c. Deceleration followed by acceleration of 15 bpm d. Decrease in variability for 15 seconds

a. A normal active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and normal periodic change in fetal heart rates as a response to fetal movement. Normal variability is noted to occur within 6 to 25 bpm from the baseline FHR. There should be no decelerations.

A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility? a. increased risk of infection b. potential rapid birth of fetus c. potential placenta previa d. increased risk of breech presentation

a. After the amniotic sac has ruptured, the barrier to infection is gone, and an ascending infection is possible. In addition, there is a danger of cord prolapse. The spontaneous rupture does not hasten labor, although it might signal the beginning of labor. The client may have placenta previa with the membranes intact.

A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic? a. relaxin b. progesterone c. oxytocin d. prolactin

a. As the pregnancy progresses, the hormones relaxin and estrogen cause the connective tissues to become more relaxed and elastic and cause the joints to become more flexible to prepare the mother's pelvis for birth. Progesterone, oxytocin, and prolactin are not involved.

Which nursing action is a priority when the fetus is at the +4 station? a. Have a blue bulb suction and an infant warmer ready. b. Have a tocometer and a client gown ready. c. Provide lubricating jelly and an internal monitor. d. Prepare for an immediate cesarean birth.

a. At +4 station, the fetus is being born. The priority nursing action is to have a blue bulb or suction device for airway clearance and an infant warmer ready. During admission, the nurse will place a tocometer on the maternal stomach and have a gown ready. For checking effacement and dilation (dilatation), the nurse will have a lubricant and possibly an internal monitor per health care provider orders. A cesarean birth is not needed as the fetus has progressed through the birth canal.

The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor? a. "She is in active labor; she is progressing at this point and we will keep you posted." b. "She is in the transition phase of labor, and it will be within 2 to 3 hours, though it might be sooner." c. "She is still in early latent labor and has much too long to go to tell when she will give birth." d. "She is doing well and is in the second stage; it could be anytime now."

a. At 7 cm dilated, she is considered in the active phase of labor. There is no science that can predict the length of labor. She is progressing in labor, and it is best not to give the family a specific time frame.

A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor? a. These contractions help in softening and ripening the cervix. b. These contractions increase the release of prostaglandins. c. These contractions increase oxytocin sensitivity. d. These contractions make maternal breathing easier.

a. Braxton Hicks contractions assist in labor by ripening and softening the cervix and moving the cervix from a posterior position to an anterior position. Prostaglandin levels increase late in pregnancy secondary to elevated estrogen levels; this is not due to the occurrence of Braxton Hicks contractions. Braxton Hicks contractions do not help in bringing about oxytocin sensitivity. Occurrence of lightening, not Braxton Hicks contractions, makes maternal breathing easier.

A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor? a. Radiates from the back to the front b. Slows when the woman changes position c. Occurs in an irregular pattern d. Lasts about 20 to 25 seconds

a. Contractions that begin in the back and then radiate to the front are typical of true labor. Contractions that slow when a woman walks or changes position suggest false labor, as do irregular contractions. Contractions lasting 30 seconds or less commonly suggest Braxton Hicks contractions and are associated with false labor.

Which cardinal movement of delivery is the nurse correct to document by station? a. Descent b. Flexion c. Extension d. Internal rotation

a. Descent is documented by station, which is the relationship of the fetal presenting part to the maternal ischial spines. Descent continues throughout labor until the fetus reaches the fetal station of +4. The other options represent fetal movements to accommodate the passage of the fetus.

The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first? a. Assess and reposition the woman. b. Notify the registered nurse. c. Notify the health care provider. d. Wait 2 minutes to review another tracing.

a. Due to maternal movement, the fetal heart monitor may become dislodged and not provide accurate tracings. Reposition and assess the woman to note any change with the next contraction. If concern remains, notify the registered nurse. The registered nurse will interpret the tracing and notify the health care provider.

Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide? a. lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels b. release of endorphins in response to the uterine contractions c. distraction of the brain cortex by other stimuli occuring in the body d. blocking of nerve transmission via mechanical irritation of nerve fibers

a. During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it. Distraction and mechanical irritation of nerve fibers are also methods of reducing pain, not causes of pain.

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention? a. Help the woman change positions. b. Obtain assistance to check for a compressed umbilical cord. c. Prepare the woman for an emergency cesarean birth. d. Document the finding.

a. First, the nurse should assist the woman to change positions and try to find a position that is comfortable for the woman that relieves the compression. If the variables stop after the position change, the nurse will know that the compression has been relieved. However, if the variables continue, the nurse should try a variety of position changes, including the knee-chest position.

The nurse has been asked to present information to a group of civic leaders concerning women's health issues. In preparing the information, the nurse includes what goal from Healthy People 2030 related to women in labor? a. Reduce the rate of cesarean births among low-risk women. b. Encourage women with previous cesareans to always have a cesarean. c. Ensure care during labor includes immunizations. d. Ensure all couples receive preconception genetic counseling.

a. Healthy People 2030 includes one goal related to cesarean births in the United States, "Reduce cesarean births among low-risk women with no prior births." Immunizations and genetic counseling are not associated with women in labor.

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is: a. 7.15 or less. b. 7.25 or more. c. 7.20. d. 7.21.

a. In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress.

To assess the frequency of a woman's labor contractions, the nurse would time: a. the beginning of one contraction to the beginning of the next. b. the end of one contraction to the beginning of the next. c. the interval between the acme of two consecutive contractions. d. how many contractions occur in 5 minutes.

a. Measuring from the beginning of one contraction to the next marks the time between contractions.

When explaining to a class of pregnant women why labor begins, the nurse will include the fact that there are several theories that have been proposed to explain why labor begins, although none have been proven scientifically. Which idea is one of those theories? a. change in estrogen-to-progesterone ratio b. decrease in number of oxytocin receptors c. decrease in the level of estrogen d. decrease in prostaglandins, leading to myometrium contractions

a. One of the theories suggests that labor is initiated by a change in the estrogen-to-progesterone ratio. The number of oxytocin receptors have been noted to increase. Estrogen levels also increase, which in turn increases myometrial sensitivity to oxytocin. Prostaglandin levels also increase, which in turn leads to myometrial contractions.

The nurse cares for a pregnant client in labor and determines the fetus is in the right occiput anterior (ROA) position. Which action by the nurse is best? a. Continue to monitor the progress of labor. b. Auscultate fetal heart rate (FHR) in the left upper quadrant. c. Prepare the client for cesarean birth of the fetus. d. Educate the client this fetal position may result in a longer labor.

a. ROA (right occiput anterior) means the occiput of the fetal head points toward the mother's right anterior pelvis; the head is the presenting part. This is a common and favorable position for vaginal birth. Based on the ROA location, the nurse will auscultate FHR at the right lower quadrant of the client's abdomen (FHR will be loudest where the fetus' back is located). Occiput posterior (not anterior) positions are associated with longer, more difficult births.

How does a woman who feels in control of the situation during labor influence her pain? a. Feelings of control are inversely related to the client's report of pain. b. Decreased feeling of control helps during the third stage. c. There is no association between the two factors. d. Feeling in control shortens the overall length of labor.

a. Studies reveal that women who feel in control of their situation are apt to report less pain than those who feel they have no control.

A primigravida client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize? a. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." b. "This is not normal unless you are in active labor; come to the hospital and be checked." c. "That is something we expect with a second or third baby, but because it is your first, you need to be checked." d. "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital."

a. The baby can drop into the pelvis, an event termed lightening, and can happen for up to 2 weeks before the woman goes into labor. This is normal and does not require intervention.

The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible? a. Molding b. Caput succedaneum c. Cephalohematoma d. Vertex presentation

a. The cartilage between the bones allows the bones to overlap during labor, a process called molding that elongates the fetal skull, thereby reducing the diameter of the head.

The nurse is performing Leopold maneuvers as part of the initial assessment. Which action would the nurse do first? a. Feel for the fetal buttocks or head while palpating the abdomen. b. Feel for the fetal back and limbs as the hands move laterally on the abdomen. c. Palpate for the presenting part in the area just above the symphysis pubis. d. Determine flexion by pressing downward toward the symphysis pubis.

a. The first maneuver involves feeling for the buttocks and head at the uterine fundus. Next, the nurse palpates on the side the fetal back is located. The third maneuver determines presentation and involves palpating the area just above the symphysis pubis. The final maneuver determines attitude and involves applying downward pressure in the direction of the symphysis pubis.

The five "Ps" of labor are: a. passageway, passenger, position, powers, psych. b. passenger, posture, position, presentation, psych. c. passenger, position, presentation, pushing, psych. d. passenger, position, powers, presentation, psych.

a. The five "Ps" are passageway (birth canal), passenger (fetus and placenta), position (maternal), powers (contractions), and psych (maternal psychological response).

A client has just received combined spinal epidural. Which nursing assessment should be performed first? a. Assess vital signs. b. Assess pain level using a pain scale. c. Assess for progress in labor. d. Assess for spontaneous rupture of membranes. e. Assess for fetal tachycardia.

a. The most common side effect of spinal and epidural anesthesia is hypotension, which can lead to fetal bradycardia, decelerations, or fetal distress. Although each is important, assessment of vital signs should be performed first.

The nurse is caring for a client who received a dose of IV sedation, given by the charge nurse, 30 minutes prior. What action is appropriate? a. Remind the client to call for assistance before getting out of bed. b. Restrict the client's fluid to further prevent constipation from the medication. c. Assure the fetal heart tones are assessed every 2 to 3 hours via monitoring. d. Remind the client that medication will assist in relieving pain from contractions.

a. The nurse will remind the client to call for help before getting out of bed to prevent falling from the sedation effects. The nurse would not expect sedatives to cause constipation if given for a limited time during labor. Fetal heart tones are assessed continuously to monitor for side effects of decreased fetal heart rate variability secondary to maternal sedatives. Sedatives do not relieve pain but may provide an opportunity to sleep and decreases anxiety during labor.

The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching? a. Longitudinal b. Transverse c. Obtuse d. Oblique

a. The picture shows the fetus parallel to the maternal spine, which denotes the longitudinal lie. In the transverse lie, the fetus lies crosswise to the maternal spine. An oblique lie is between the two. There is not an obtuse lie.

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? a. Fetal heart rate in relation to contractions b. The station in which the fetus is located c. Maternal heart rate and blood pressure d. Maternal request for pain medication

a. The priority consideration is on the status of the fetus. Because each contraction temporarily interrupts blood flow to the placenta, there is a decrease in oxygen available. Therefore, a fetus cannot tolerate contractions lasting too long or too strong. All other options are important but not the priority.

A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation (dilatation) to occur? a. cervical ripening and softening b. Braxton Hicks contractions c. bloody show d. lightening

a. The ripening and softening of the cervix that result from the effects of prostaglandins and pressure from Braxton Hicks contractions are essential for effacement and dilation (dilatation) of the cervix. Lightening occurs when the fetal presenting part begins to descend into the true pelvis. Bloody show occurs as the mucus plug is expelled as a result of cervical softening and increased pressure of the presenting part.

Which psychosocial state is anticipated when the client enters the active phase of labor? a. The client will become more quiet and introverted. b. The client will become angry and begin to scream. c. The client will become more talkative and excited about the birth. d. The client will become tired and want the process over.

a. The woman's psychosocial state typically changes as she enters the active phase of labor. As the contractions are increasing in amount and intensity, the woman becomes more quiet and introverted as she is focused on the work of labor. The other options may occur but are not anticipated.

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do? a. Palpate the mother's radial pulse at the same time. b. Ask the woman to hold her breath while assessing the FHR. c. Have the woman lie completely flat on her back while auscultating. d. Instruct the woman to bend her knees and flex her hips.

a. To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen. Having the woman hold her breath would be inappropriate and possibly dangerous. Lying flat or bending the knees and flexing the hips would have no effect on determining if the heart rate being assessed is of the fetus or the mother.

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia? a. Difficulty breathing b. Staggering gait c. Decreased level of consciousness d. Intense pain

a. Total spinal blockade occurs when an inadvertent injection of a local anesthetic is placed into the intrathecal or epidural space. The resulting effect is that the anesthetic travels too high in the body causing paralysis of the respiratory muscles. Difficulty breathing is a sign. A decreased level of consciousness will occur later. A staggering gait or intense pain is not a primary symptom.

A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement? a. "I feel pressure in my vagina when I have the contraction." b. "I will have a strong one and then the next one will be weaker." c. "I feel the tightening primarily in the front of my belly." d. "The contractions lessen after I drink a large glass of water."

a. True labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement. True labor contractions are regular, becoming closer together, getting stronger with time with pressure in the vagina being felt. In contrast, false labor contractions are usually felt in the front of the abdomen, alternate in intensity (strong one followed by a weaker one), and diminish with activity, position changes, and drinking fluids.

While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents? a. FHR fluctuates from 6 to 25 beats per minute. b. FHR fluctuation range is undetectable. c. FHR fluctuates less than 5 beats per minute. d. FHR fluctuates over 25 beats per minute.

a. Variability is described in four categories: absent, fluctuations range undetectable; minimal, fluctuations range observed at <5 beats per minute; moderate (normal), fluctuation range from 6 to 25 beats per minute; and marked, fluctuation range >25 beats per minute.

The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client? a. Massage therapy b. Continuous labor support c. Pharmacologic pain management d. Prenatal classes

b. Continuous labor support by a caring nurse or doula can help decrease a woman's anxiety during labor. Anxiety causes the release of catecholamines, which slow down the labor process. The continuous support helps keep the woman focused on what is important as well as provide necessary guidance and education as needed. The massage therapy, prenatal classes, and pharmacologic pain management are all tools that the nurse can use to help the woman.

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states: a. "Effleurage is the pattern for cleaning the perineum before birth." b. "Effleurage is light abdominal massage used to displace pain." c. "Effleurage is the effect of a full bladder on fetal descent." d. "Effleurage is massaging the perineum as the fetus enlarges the vaginal opening."

b. Effleurage is a light abdominal massage used to keep the laboring woman's focus on the massage instead of the pain of labor.

A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will: a. lead the client through a series of visualizations to aid in relaxation. b. instruct the client or her partner to perform light fingertip repetitive abdominal massage. c. instruct the client to perform controlled chest breathing with a slow inhale and a quick exhale. d. press down firmly with her index finger and forefinger on key trigger points on the client's ankle or wrist.

b. Effleurage is light fingertip repetitive abdominal massage. The relaxation technique of visualization is used in hypnobirthing or focused meditation. Controlled chest breathing is a technique used in Lamaze breathing. Pressing on trigger points is an acupressure technique.

A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds that can prolong labor. The nurse is referring to which compounds? a. prostaglandins b. catecholamines c. oxytocin d. relaxin

b. Fear and anxiety cause the release of catecholamines, such as norepinephrine and epinephrine, which stimulate the adrenergic receptors of the myometrium. This in turn interferes with effective uterine contractions and results in prolonged labor. Estrogen promotes the release of prostaglandins and oxytocin. Relaxin is a hormone that is involved in producing backache by acting on the pelvic joints. Prostaglandins, oxytocin, and relaxin are not produced due to fear or anxiety in clients during labor.

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing? a. Inhale and exhale through the mouth at a rate of 4 breaths every 5 seconds. b. Inhale slowly through nose and exhale through pursed lips. c. Punctuated breathing by a forceful exhalation through pursed lips every few breaths. d. Hold breath for 5 seconds after every 3 breaths.

b. For slow-paced breathing, the nurse should instruct the woman to inhale slowly through her nose and exhale through pursed lips. In shallow or modified-pace breathing, the woman should inhale and exhale through her mouth at a rate of 4 breaths every 5 seconds. In pattern-paced breathing, the breathing is punctuated every few breaths by a forceful exhalation through pursed lips. Holding the breath for 5 seconds after every three breaths is not recommended in any of the three levels of patterned breathing.

A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage? a. Immersing the client in warm water in a pool or hot tub b. Practicing effleurage on the abdomen c. Administering a sedative such as secobarbital or pentobarbital d. Administering an opioid such as meperidine or fentanyl

b. In early labor, the less medication use the better; allow use of nonpharmacologic management and control the pain with effleurage. Sitting in a warm pool of water is relaxing and may lessen the pain, but it does not control the pain. Sedatives are not indicated as they may slow the birthing process. Opioids should be limited as they too may slow the progression of labor.

A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response? a. Suggest a less extreme alternative such as a sedative. b. Support the client's decision and call the provider. c. Gently remind the client of her goal of a natural birth and encourage and help her. d. Ask the husband to gently remind her of their goal of natural birth and to encourage and help her.

b. Pain is subjective and its level is only what the client experiences. The nurse should support the desire of the client. Sedatives would be counterproductive as they may slow the labor process. It would be inappropriate to negate her feelings and remind her of earlier goals; that is the job of the support person and should be left up him or her to decide what to say and when to say it.

A client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxia. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending? a. Alert the team that internal fetal monitoring may be needed. b. Palpate the area just above the symphysis pubis. c. Institute effleurage and apply pressure to the client's lower back during contractions. d. Encourage the client to push.

b. Palpate just above the symphysis pubis to determine if the infant is engaged and to determine the presenting part of the infant; it is possible for infants to rotate and change position during labor. The nurse should assess the situation and act further if necessary, but until there is more information on the fetal position, the nurse should assume all is going well.

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? a. variable decelerations b. prolonged decelerations c. early decelerations d. accelerations

b. Prolonged decelerations are associated with prolonged cord compression, placental abruption (abruptio placentae), cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture. Variable decelerations are the most common deceleration pattern found. They are usually transient and correctable. Early decelerations are thought to be the result of fetal head compression. They are not indicative of fetal distress and do not require intervention. Fetal accelerations are transitory increases in FHR and provide evidence of fetal well-being.

A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client? a. accidental intrathecal block b. respiratory depression c. postdural puncture (spinal) headache d. a failed block

b. Respiratory depression is a complication of epidural anesthesia and should be closely monitored in laboring clients. A failed block, accidental intrathecal block, and a postdural puncture (spinal) headache are all side effects of a spinal epidural block.

A woman at 38 weeks' gestation is in labor and oxytocin is prescribed to augment her labor. When preparing to administer this medication, what action by the nurse would be appropriate? a. Give the medication as an intramuscular injection using the Z-track technique. b. Administer the medication piggybacked into a primary IV line using a pump. c. Give the medication orally every hour for the first 4 hours. d. Assist with insertion of a central venous access device for administration.

b. Synthetic oxytocin is used to induce or augment labor by stimulating uterine contractions. It is administered piggybacked into the primary intravenous line with an infusion pump titrated to uterine activity. It is not given orally, via IM injection, or through a central venous access device.

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway? a. False pelvis b. Cervix c. Perineum d. Uterus

b. The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.

A labor nurse is caring for a client who is 7 cm dilated, 100% effaced, at a +1 station, and has a face presentation on examination. The nurse knows that teaching was understood when the birth partner makes which statement? a. "Our baby will come out facing the hip." b. "Our baby will come out face first." c. "Our baby will come out with the back of the head first." d. "Our baby will come out with the buttocks first."

b. The fetal presentation pertains to the part of the fetus that comes through the cervix and the birth canal first. A face presentation indicates that the face presents first. The face is a large part of the head, so caution must be used.

A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture? a. Bloody fluid b. Clear to straw-colored fluid c. Greenish fluid d. Cloudy white fluid

b. The infant is in the correct position, and the client has been in labor. Expectation would be for normal amniotic fluid presentation of clear to straw-colored fluid. If there is blood, then the uterus is bleeding and there is an extreme emergency. If the fluid is greenish, there is meconium in the fluid. Cloudy, white fluid may indicate an infection is present.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? a. Help the woman to sit up in a semi-Fowler's position. b. Turn her or ask her to turn to her side. c. Administer oxygen at 3 to 4 L by nasal cannula. d. Ask her to pant with the next contraction.

b. The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation? a. crowning b. effacement c. dilation (dilatation) d. molding

b. The nurse is explaining about effacement, which involves softening, thinning, and shortening of the cervical canal. Dilation (dilatation) refers to widening of the cervical os from a few millimeters in size to approximately 10 cm wide. Crowning refers to a point in the maternal vagina from where the fetal head cannot recede back after the contractions have passed. Molding is a process in which there is overriding and movement of the bones of the cranial vault, so as to adapt to the maternal pelvis.

A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia? a. passage of the drug to the fetus b. headache following anesthesia c. excessive contractions of the uterus d. increased frequency of micturition

b. The nurse should inform the client and her family about the possibility of headache after spinal anesthesia. The drug is retained in the mother's body and not passed to the fetus. There may be uterine atony, and not excessive uterine contractions, following spinal anesthesia. Spinal anesthesia may lead to bladder atony, and not an increased frequency of micturition.

A pregnant client in labor has to undergo a sonogram to confirm the fetal position of a shoulder presentation. For which condition associated with shoulder presentation during a vaginal birth should the nurse assess? a. uterine abnormalities b. fetal anomalies c. congenital anomalies d. birth after due date

b. The nurse, along with the primary care provider, has to assess for fetal anomalies, which are usually associated with a shoulder presentation during a vaginal birth. The other conditions include placenta previa and multiple gestations. Uterine abnormalities, congenital anomalies, and prematurity are conditions associated with a breech presentation of the fetus during a vaginal birth.

A client in her third trimester comes to the clinic for an evaluation. Assessment reveals that the cervix is thinning. The client says, "I know my cervix needs to dilate, but why does it get thinner?" Which response by the nurse would be appropriate? a. "Your cervix thins so that your contractions can increase." b. "You need the cervix to thin so it can stretch more easily." c. "It thins to let your baby change positions during labor." d. "Cervical thinning is a sign that you are in true labor."

b. The rigid cervix of pregnancy must become distensible to expel the fetus. Before labor begins, cervical softening and possible cervical dilation with descent of the presenting part into the pelvis occur. These changes can occur 1 month to 1 hour before actual labor begins. As labor approaches, the cervix changes from an elongated structure to a shortened, thinned segment. Cervical collagen fibers undergo enzymatic rearrangement into smaller, more flexible fibers that facilitate water absorption, leading to a softer, more stretchable cervix. These changes occur secondary to the effects of prostaglandins and pressure from Braxton Hicks contractions. Cervical thinning has no effect on contractions or fetal positioning. It is not a sign of true labor.

A nurse is providing care to a woman in labor. When reviewing the woman's medical record, the nurse notes that fetal position is documented as LSA. The nurse interprets this to mean that which part of the fetus is presenting? a. occiput b. buttocks c. chin d. acromion process

b. The second letter of LSA denotes the presenting part. In this case, it is "S" which is for sacrum or buttocks. "O" refers to the occiput; "M" would be used to refer to the chin. "A" would be used to refer to the acromion process.

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? a. Admission time and time of fetal birth b. Complete cervical dilation (dilatation) and time of fetal birth c. Effacement time and time when contractions are regular d. Time of mucus plug expulsion and full cervical dilation

b. The second stage of labor begins with complete cervical dilation (dilatation) of 10 cm and ends with delivery of the neonate.

A client in labor has been admitted to the labor and birth suite. The nurse assessing the woman notes that the fetus is in a cephalic presentation. Which description should the nurse identify by the term presentation? a. relationship of the presenting part to the maternal pelvis b. part of the fetal body entering the maternal pelvis first c. relation of the fetal presenting part to the maternal ischial spine d. relation of the different fetal body parts to one another

b. The term presentation is the part of the fetal body that is entering the maternal pelvis first. The relationship of the presenting part to the sides of the maternal pelvis is called the position. Attitude is the term that describes the relation of the different fetal body parts to one another. The relation of the fetal presenting part to the maternal ischial spine is termed the station.

A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor? a. The contraction pains are 2 minutes apart and 1 minute in duration. b. The client reports back pain, and the cervix is effacing and dilating. c. The contraction pains have been present for 5 hours, and the patterns are regular. d. After walking for an hour, the contractions have not fully subsided.

b. True labor is indicated when the cervix is changing. Contractions occur for weeks before true labor, and may occur close together. Contractions may also occur for a long time before true labor begins.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? a. shoulders b. occiput c. brow d. buttocks

b. With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.

A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse? a. "An injury is unlikely because of expert professional care given." b. "I have never read or heard of this happening." c. "The injection is given in the space outside the spinal cord." d. "The injection is given at the third or fourth thoracic vertebrae so paralysis is not a problem."

c. An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.

A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings? a. The client is in active labor. b. The duration of the contractions is every 5 minutes. c. The frequency of the contractions is every 5 minutes. d. The client can be sent home.

c. Based on the information, the nurse knows the contractions are regular and every 5 minutes apart. This is the only data gathered based on the information given, but it is very useful to the provider. A change in the cervix is necessary for active labor. This client will need further assessment to determine whether the client can go home or should be prepared for active labor. There is no information providing the duration of the contractions.

A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? a. every 5 minutes b. every 10 minutes c. every 15 minutes d. every 20 minutes

c. During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour.

Which is the most important nursing assessment of the mother during the fourth stage of labor? a. The mother's psyche b. Blood pressure c. Hemorrhage d. Heart rate

c. During the fourth stage of labor, there is a period of recovery for the mother after delivery of the placenta. During this time, the nurse's assessment focuses heavily on watching for signs of hemorrhage. Hemorrhage may occur from such things as lacerations or retained placenta fragments. The mother's psyche is a concern during the labor process. At the conclusion of the birth process, the mother's psyche is typically positive. Blood pressure and heart rate as also monitored and can be an indicator of hemorrhage.

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize? a. maternal hypotension and fetal tachycardia b. maternal hypertension and fetal bradycardia c. maternal hypotension and fetal bradycardia d. maternal hypertension and fetal tachycardia

c. Epidural anesthesia conveys the risk of hypotension, especially if the client has not received an adequate amount of fluid before the procedure is performed. A sudden drop in maternal blood pressure can cause uterine hypoperfusion, which may result in fetal bradycardia. The other choices are not an adverse effect of epidural anesthesia.

To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? a. lying supine with legs in lithotomy stirrups b. squatting while holding her breath c. head elevated, grasping knees, breathing out d. lying on side, arms grasped on abdomen

c. For the most effective pushing during the second stage of labor, a woman should wait to feel the urge to push even though a pelvic exam has revealed she is fully dilated. Pushing is usually best done from a semi-Fowler's position with legs raised against the abdomen, squatting, or on all fours rather than lying flat to allow gravity to aid the effort .Make sure the woman pushes with contractions and rests between them. She can use short pushes or long, sustained ones, whichever feels more comfortable. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to her heart because of increased intrathoracic pressure, which could then also interfere with blood supply to the uterus. To prevent her from holding her breath during pushing, urge her to grunt or breathe out during a pushing effort (as tennis players do).

The nurse is determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse documents this finding as: a. duration. b. intensity. c. frequency. d. peak.

c. Frequency refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction. Duration refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The peak or acme of a contraction is the highest intensity of a contraction.

General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks? a. The client is more sensitive to preanesthetic medications. b. The client is less sensitive to inhalation anesthetics. c. Neonatal depression is possible. d. Fetal hypersensitivity to anesthetic is possible.

c. General anesthesia is not used frequently in obstetrics because of the risks involved. The pregnant woman is at higher risk for aspiration. It requires more skill to intubate a pregnant woman because of physiologic changes in the trachea and thorax. In addition, general anesthetic agents cross the placenta and can result in the birth of a severely depressed neonate who requires full resuscitation.

The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize? a. Fetal heart rate b. Possible maternal infection c. Green-colored fluid in the vagina d. Irregular contractions

c. Green-tinted fluid with ROM is indicative of meconium in the amniotic sac, or the infant having a bowel movement in utero. Infection would be shown by pus or cloudy fluid and possibly an elevated temperature. The FHR is within normal range. Irregular contractions are expected at this stage of labor.

A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position? a. Long axis of fetus is at 60° to that of client. b. Long axis of fetus is parallel to that of client. c. Long axis of fetus is perpendicular to that of client. d. Long axis of fetus is at 45° to that of client.

c. If the long axis of the fetus is perpendicular to that of the mother, then the client's fetus is in the transverse lie position. If the long axis of the fetus is parallel to that of the mother, the client's fetus is in the longitudinal lie position. The long axis of the fetus being at 45° or 60° to that of the client does not indicate any specific position of the fetus.

A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure? a. promoting the woman's feelings of control b. providing clear information about procedures c. allowing the woman time to be alone d. encouraging the woman to use relaxation techniques

c. Positive support, not being alone, promotes a positive birth experience. Being alone can increase anxiety and fear, decreasing the woman's ability to cope. Feelings of control promote self-confidence and self-esteem, which in turn help the woman to cope with the challenges of labor. Information about procedures reduces anxiety about the unknown and fosters cooperation and self-confidence in her abilities to deal with labor. Catecholamines are secreted in response to anxiety and fear and can inhibit uterine blood flow and placental perfusion. Relaxation techniques can help to reduce anxiety and fear, in turn decreasing the secretion of catecholamines and ultimately improving the woman's ability to cope with labor.

A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent? a. First b. Second c. Third d. Fourth

c. Stage three begins with the birth of the baby and ends with delivery of the placenta.

A pregnant client wants to know why the labor of a primigravida usually lasts longer than that of a woman who has already given birth once and is pregnant a second time. What explanation should the nurse offer the client? a. Braxton Hicks contractions are not strong enough during first pregnancy. b. Contractions are stronger during the first pregnancy than the second. c. The cervix takes around 12 to 16 hours to dilate during first pregnancy. d. Spontaneous rupture of membranes occurs during first pregnancy.

c. The labor of a primigravida lasts longer because during the first pregnancy the cervix takes between 12 and 16 hours to dilate completely. The intensity of the Braxton Hicks contractions stays the same during the first and second pregnancies. Spontaneous rupture of membranes may occur before the onset of labor during each birth, not only during the first birth.

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding? a. presentation b. attitude c. lie d. position

c. The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to be longitudinal. Presentation is the portion of the fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis.

A pregnant woman at 37 weeks' gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are: a. occurring in the abdomen and groin. b. lasting about 30 seconds. c. occurring about every 5 minutes. d. relieved by walking.

c. The nurse needs to determine if the client is experiencing true labor contractions. True labor contractions are commonly felt in the lower back, in contrast to Braxton Hicks contractions that typically last about 30 seconds and occur primarily in the abdomen and groin and are relieved by walking, voiding, eating, increasing fluid intake, or changing positions. However, if contractions last longer than 30 seconds and occur more often than 4 to 6 times per hour, the nurse should have the woman evaluated, especially if she is less than 38 weeks' pregnant.

A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus? a. LOA b. LOP c. ROA d. ROP

c. The nurse should document the fetal position in the clinical record using abbreviations. The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.

The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows: a. internal rotation, descent, extension, flexion, external rotation, expulsion b. descent, flexion, external rotation, extension, internal rotation, expulsion c. descent, flexion, internal rotation, extension, external rotation, expulsion d. internal rotation, flexion, descent, extension, external rotation, expulsion

c. The six cardinal movements of the fetus, in order, are descent, flexion, internal rotation, extension, external rotation, and expulsion.

During which time is the nurse correct to document the end of the third stage of labor? a. Following fetal birth b. When pushing begins c. At the time of placental delivery d. When the mother is moved to the postpartum unit

c. The third stage of labor concludes with the delivery of the placenta. The nurse is correct to document that time in the medical record. The beginning of the third stage of labor is the documented time of birth. Neither the time when the woman begins to push nor when she is moved to the postpartum unit are notable.

The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor? a. transition phase b. stage two c. latent phase d. stage three

c. The woman in labor undergoes numerous psychological adaptations during labor. During the latent phase, she is often talkative and happy, and yet anxious. During transition, the client may show fear and anger. During stage 2 she may remain positive, but the work of labor is very intense.

The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize? a. Administer oxygen. b. Increase her IV fluids. c. Change the position of the client. d. Notify the primary care provider.

c. Variable decelerations often indicate a type of cord compression. The initial response is to change the position and try to release the cord compression. If this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate.

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned? a. Fetal station b. Fetal attitude c. Fetal position d. Fetal size

c. When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference. Fetal station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. Fetal attitude refers to the relationship of the fetal parts to one another. Fetal size refers the actual size of the developing fetus.

The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which? a. The client is fully effaced. b. The fetus is floating high in the pelvis. c. The fetus is in the true pelvis and engaged. d. The fetus has descended down the birth canal.

c. When the fetus is at a 0 (zero) station, it is at the level of the ischial spines and said to be engaged. Determining the station does not mean that the client's cervix is fully effaced. If the fetus is floating high in the pelvis, its station is noted as a negative number. Descending into the pelvis or birth canal is documented as a positive number.

The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's plan of care? a. A woman should be left entirely alone during this period. b. A woman will rarely speak or laugh during this period. c. A woman may spend time thinking about what is happening to her. d. No nursing care is needed to be done during this time.

c. Women need a support person with them during all stages of labor.

The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out "0 station" refers to which sign? a. "This is just a way of determining your progress in labor." b. "This indicates that you start labor within the next 24 hours." c. "This means +1 and the baby is entering the true pelvis." d. "The presenting part is at the true pelvis and is engaged."

d. 0 station is when the fetus is engaged in the pelvis, or has dropped. This is an encouraging sign for the client. This sign is indicative that labor may be beginning, but there is no set time frame regarding when it will start. Labor has not started yet, and the fetus has not begun to move out of the uterus.

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering? a. Assess maternal blood pressure. b. Assess for constipation. c. Assess for dry mouth. d. Assess fetal heart rate.

d. After administering an opioid to a laboring mother, the priority is to assess the impact on the fetus. Opioid administration can cross the placental barrier and affect fetal heart rate and variability. After birth, there may be a decrease in alertness of the neonate. Maternal factors of decreased blood pressure, constipation, and dry mouth are of a lower priority.

A nurse is monitoring a woman in labor. Which assessment finding is most concerning to the nurse? a. Client begins vomiting. b. Blood pressure is 128/82 mm Hg. c. Respiratory rate is 22 breaths/minute. d. Temperature is 101.6°F (38.7°C).

d. Although slight temperature elevations are normal during labor, a temperature of 101.6°F (38.7°C) indicates an infection and should be reported to the health care provider. As the woman progresses through birth, numerous physiologic responses occur that assist her to adapt to the laboring process. Some of these changes include heart rate increasing by 10 to 20 beats per minute; blood pressure increases by up to 35 mm Hg; and respiratory rate increases as more oxygen is consumed. Nausea and vomiting are common during labor, especially during the transition phase, due to decreased gastric motility.

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? a. -5 b. 0 c. +1 d. +4

d. As the fetus is being born, the fetus is at +4 station. The fetus is floating and not engaged in the pelvis at -5 station. The fetus is at the level of the ischial spines and engaged at 0 station. The fetus is progressing down the birth canal below the ischial spines at +1 station.

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother? a. The father's coaching role may be disrupted at times. b. The infant may show increased drowsiness. c. The mother may have continued memory loss postpartum. d. The mother may have difficulty working effectively with contractions.

d. Breathing and relaxation techniques can speed labor. An inability of the woman to do these as a result of pain relief measures can slow labor.

The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process? a. engagement b. descent c. restitution d. crowning

d. Crowning occurs when the top of the fetal head appears at the vaginal orifice and no longer regresses between contractions. Engagement occurs when the greatest transverse diameter of the head passes through the pelvic inlet. Descent is the downward movement of the fetal head until it is within the pelvic inlet. Restitution or external rotation occurs after the head is born and free of resistance. It untwists, causing the occiput to move about 45 degrees back to its original left or right position.

The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist? a. Dry, cracked lips b. Urinary retention c. Rapid progress of labor d. Inability to push

d. If the client is not able to push, her epidural dose may need to be adjusted to decrease the impact on the sensory system. Dry lips indicate that she may need fluids, so the nurse should give her some ice chips or a drink of water. Urinary retention and rapidly progressing labor should be directly reported to the obstetrician, not the anesthesiologist.

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? a. a shallow deceleration occurring with the beginning of contractions b. variable decelerations, too unpredictable to count c. fetal baseline rate increasing at least 5 mm Hg with contractions d. fetal heart rate declining late with contractions and remaining depressed

d. Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.

The client may spend the latent phase of the first stage of labor at home unless which occurs? a. The client passes the bloody show b. The contractions vary in length and intensity c. The client begins back labor d. The client experiences a rupture of membranes

d. Once the client experiences a rupture of membranes, the client is instructed to report to the health care facility. When the rupture of membranes occurs, there is a potential for infection. Also, assessment of the client is required as this is the time of greatest threat of a prolapsed cord. The client may remain at home for all other options.

During the second stage of labor, a woman is generally: a. very aware of activities immediately around her. b. anxious to have people around her. c. no longer in need of a support person. d. turning inward to concentrate on body sensations.

d. Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.

A pregnant client is admitted to a maternity clinic for birth. The client wishes to adopt the kneeling position during labor. The nurse knows that which of the following is an advantage of adopting a kneeling position during labor? a. It helps the woman in labor to save energy. b. It facilitates vaginal examinations. c. It facilitates external belt adjustment. d. It helps to rotate the fetus in a posterior position.

d. The advantage of adopting a kneeling position during labor is that it helps to rotate the fetus in a posterior position. Facilitating vaginal examinations, facilitating external belt adjustment, and helping the woman in labor to save energy are advantages of the back-lying maternal position.

The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: a. right upper quadrant. b. right lower quadrant. c. left upper quadrant. d. left lower quadrant.

d. The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.

A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client? a. diffuse abdominal cramping b. rupturing of fetal membranes c. start of regular contractions d. dilation (dilatation) of cervix diameter to 10 cm

d. The first stage of labor terminates with the dilation (dilatation) of the cervix diameter to 10 cm. Diffused abdominal cramping and rupturing of the fetal membrane occur during the first stage of labor. Regular contractions occur at the beginning of the latent phase of the first stage; they do not mark the end of the first stage of labor.

The nursing instructor is teaching the students the basics of the labor and delivery process. The instructor determines the session is successful when the students correctly choose which action will best help to prevent infections in their clients? a. Clean the woman's perineum with a Betadine scrub. b. Strictly follow universal precautions. c. Replace soiled drapes and linen as needed. d. Thoroughly wash the hands before and after client contact.

d. The most important infection control technique in any health care setting is thoroughly washing hands on a routine basis. Keeping the area clean is secondary but also important.

A pregnant client is admitted to the labor and birth unit in the first stage of labor. A nurse reviews a pregnant client's birth plan. Which response from the client would indicate to the nurse that further teaching is indicated? a. "My 6-year old son will be in the birthing room, too." b. "I would like the baby's father to cut the umbilical cord." c. "We will hire a doula for our labor support." d. "I will remain in my bed for my labor and birth like last time."

d. The nurse should educate the client that she will be encouraged to get out of bed during labor. In the labor and birth process, many positions, ambulation, and water therapy may be used for comfort and positioning. All other answers are appropriate client responses.

A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor? a. effacement and dilation (dilatation) of the cervix b. shortening of the upper uterine segment c. reduction in length of the cervical canal d. restoration of blood flow to uterus and placenta

d. The pauses between contractions during labor are important because they allow the restoration of blood flow to the uterus and the placenta. Shortening of the upper uterine segment, reduction in length of the cervical canal, and effacement and dilation (dilatation) of the cervix are other processes that occur during uterine contractions.

Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation? a. cephalic b. vertex c. breech d. shoulder

d. The three main fetal presentations are cephalic or vertex, with the head as the presenting part, breech, with the pelvis as the presenting part, and shoulder, with the scapula as the presenting part.

A multigravida woman arrives in the emergency department panting and screaming, "The baby's coming!" Which action should the nurse prioritize? a. Assess maternal and fetal vital signs. b. Ask medical and obstetrical history. c. Escort to Labor and Delivery. d. Quickly evaluate the perineum.

d. The woman is showing signs of advanced labor, possibly in transition or stage 2. She needs to be managed as an imminent birth and a vaginal assessment performed, as there may not be time to get to Labor and Delivery. Vital signs would be assessed next. Medical/obstetrical history and her room assignment can be taken care of later in the process.